The Clinician as Counselor

AUTHOR:
Richard Colgan, MD

CITATION:
Colgan R. The clinician as counselor. Consultant. 2016;56(11):976-977.

Counseling using therapeutic techniques is an essential part of being a good clinician. Carl R. Rogers, one of the most influential psychologists in American history, pioneered the concept of having unconditional positive regard when counseling a patient. Unconditional positive regard involves showing complete support and acceptance of a person no matter what that person says or does. Adrienne Williams, PhD, Director of Behavioral Science in the Department of Family Medicine at the University of Illinois College of Medicine at Chicago, notes that “some therapists interpret this as meaning something along the lines of, ‘If you have to say something negative to your patient, balance it with something positive,’ so when asked to use unconditional positive regard, they will say things like, ‘You tried really hard, but you really need to do much better.’” We can practice unconditional positive regard in our relationship with each patient despite not being a psychiatrist, psychologist, or licensed clinical social worker.

One way to incorporate unconditional positive regard is to look at every clinical encounter and ask, “What can I do that would be uplifting, supportive, nurturing, and show kindness to my patient?” This may be challenging if you are seeing a child who is 6 months overdue for her well visit, particularly if she is brought in 1 hour late by her mother. In such an instance, we might go out of our way to let the mother know how important it is that she has brought her daughter in to catch up on her immunizations. This would be unconditional positive regard, as opposed to showing frustration and scolding the mother for this delay. Similarly, a 30-year, 2 packs per day smoker can be applauded for having cut down to half a pack over the past week. In fact, we can find something positive in the behaviors of everyone we see. A healer will see the technique of unconditional positive regard as an opportunity to strengthen the clinician-patient relationship. You will also improve your patient’s self-image and compliance. This is a “win-win” situation!

We may not be professional counselors, but we are professionals who counsel. To follow are some suggestions on how clinicians who are not trained therapists can use therapeutic techniques. Rogers offered 4 specific techniques that help build a therapeutic relationship with our patients.

Warmth and Responsiveness

The first is by showing warmth and responsiveness. This allows for better rapport and, in turn, leads to a deeper emotional relationship. Looking your patients in the eye and greeting them with a smile shows warmth when meeting them. Being able to see a patient who has an urgent problem, or returning their calls promptly, demonstrates respect and sensitivity to their needs as well as your responsiveness.

Permissiveness

The second quality of a therapeutic relationship is permissiveness in regard to expression of feeling. Permissiveness as used here means not being judgmental or rigid, particularly if the patient’s opinion or behaviors run contrary to our own. You may not agree with your patient’s political views, lifestyle, or religious beliefs. A doctor recently made national news for posting a sign on his office door telling patients who voted for President Barack Obama to seek care “elsewhere,” as he considered the president’s national health care overhaul to be bad medicine. This may be viewed by some as an example of not being permissive. Everyone we serve is deserving of our respect.

Therapeutic Limits

Third, we should understand the therapeutic limits of each visit with a patient. Time is one example of a limit. If a patient does arrive late, and you are unable to work them into your schedule (because you are seeing other patients who arrived on time), patients should not be free to control your schedule. Certainly, if you are able to attend to their care properly in the amount of time you have, fine. But it is also acceptable to explain to the patient that you are not able to address this concern at this time. You might add that you do not want to rush and do a suboptimal job. You can prevent this from happening by determining “all” of their goals at the beginning. “What do you want to discuss today?” perhaps followed by any specific goals you had. “I see that your blood pressure is very high. I want to be sure we address this as well.”

Freedom From Pressure

The fourth characteristic of Roger’s helpful therapeutic relationship is freedom from any type of pressure or coercion. I recognize that this is in regard to certain actions or values. I think there are times when exerting some pressure coupled with informed consent is appropriate. A patient who is resistant to going to the emergency room for atrial fibrillation or chest pain must be told in clear terms why such a strong recommendation is being made—as opposed to one resident whom I worked with who considered herself a sort of fitness guru. She frequently recommended to patients that they drink 8 glasses of water every day and take vitamins. I brought to her attention that I could not find evidence-based medical literature to support her opinion. Neither could she. She is entitled to her opinion, but Rogers might say we should not pressure our patients into doing what we want them to do.

Nonprofessionally trained therapists serving as counselors you may ask? Sure, we do it all the time. Drs. Marian R. Stuart and Joseph A. Lieberman III have written extensively on how to do just that in their book, The Fifteen Minute Hour: Therapeutic Talk in Primary Care. In this book, and in other teaching tools, they note that the goals of 15-minute therapy are: (1) preventing dire consequences; (2) reestablishing premorbid level of functioning; (3) expanding behavioral repertoire; and (4) enhancing patients’ self-esteem. The authors offer the BATHE technique as a useful tool to every clinician. “How to BATHE your patients as you SOAP them” follows:

• Background: “What is going on in your life?”
• Affect/Feeling: “How are you feeling about that?”
• Trouble: “What troubles you the most?”
• Handling: “How are you handling that?”
• Empathy: “That must be must be very difficult.”

The authors urge adoption of therapeutic skills using a new paradigm recognizing that: (1) We constantly tell ourselves and others stories; (2) these stories create our reality and affect our experience; (3) the stories reflect our view of who we are; and (4) these stories determine what we are capable of doing. The authors point out that psychotherapy means editing the story. First, the story must be heard. Second, the story must be reflected back with empathy, and third, the limits offered by the patient must be challenged. Challenging imposed limits may be identified by such words as can’t, must, should, and it’s impossible. Strategies offered for helping patients include focusing on options, looking at consequences, applying the tincture of time, and choosing not to choose. The authors go on to describe 4 options to point out in a bad situation: leave it, change it, accept it, and reframe it. By putting the patient in control, we focus on their strengths, delineate responsibility for behavior, and aim for small wins. As clinicians who counsel, we can remind our patients that the past is gone, the future is not here, and we can only act/feel in the here and now.

Simply put, Rogers tells us that we all want and need love and acceptance. This can be shown to our patients by showing them unconditional positive regard. Contemporary clinicians Stuart and Lieberman would add that our ability to listen, and the words we choose to respond with, are among the most valuable and underused tools a healer has.

Richard Colgan, MD, is  professor and vice chair for medical student education and clinical operations in the Department of Family and Community Medicine at the University of Maryland School of Medicine in Baltimore.